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Evaluation of Allergic Fungal Sinusitis Occurrence in Patients with Nasal Polyps

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Evaluation of Allergic Fungal Sinusitis Occurrence in Patients with Nasal Polyps ORIGINAL ARTICLE Evaluation of Allergic Fungal Sinusitis Occurrence in Patients with Nasal Polyps ABDUR REHMAN, FAISAL RAFIQ, ATHAR ADNAN UPPAL* ABSTRACT Aim: To evaluate allergic fungal sinusitis occurrence in patients with nasal polyps. Methods: This was a prospective descriptive study, conducted at ENT Department of Nawaz Sharif Social Security Hospital Multan Road Lahore , from January 2013 to June 2015. A total of 125 patients with nasal polyps were examined and surgery performed followed by histopathology and culture examination of surgical specimens. Results: Allergic fungal sinusitis (AFS) was found in 28/125 (22.4%) nasal polyp patients. In 28 cases of allergic fungal sinusitis, mean age was 30 years. Majority of patients (67.8%) were in the age range 20 – 40 years. Male to female ratio was 1.4:1. Most (53.5%) of AFS patients belonged to lower social class. Concomitant asthma was noted in 06 (21.4%) patients. Conclusion: Allergic fungal sinusitis is common aetiology seen among nasal polyp patients. Slightly more than one fifth of cases with nasal polyp (22.4%) had AFS in this study, While treating chronic rhinosinusitis patients, this disease entity must be kept in mind. AFS was seen to effect mainly young adults and middle aged poor people living in hot humid conditions. Aspergillus was the commonest organism responsible for AFS. Results are good if it is diagnosed early and treated properly. Keywords: Allergic fungal sinusitis (AFS), Nasal polyp, Allergic mucin. INTRODUCTION elevated total and fungus specific IgE Allergic fungal sinusitis is an allergic reaction of the concentration5,10. The involved sinuses contain brown sinonasal mucosa to aerosolized environmental 1 or greenish black material,which has been called fungal allergens in an immunocompetent person . allergic mucin, and intact and degenerating Safirstein in 1976 described a clinical condition in eosinophils, Charcot Leyden crystals, cellular debris, which there were nasal polypi and crust formation and sparse fungal hyphae4,5,11. and sinus culture producing aspergillus, having The diagnosis of AFS is primarily based on similar histopathological findings to allergic 5 2 histopathologic findings. Patients with AFS bronchopulmonary aspergillosis (ABPA) . Allergic commonly present with chronic rhinosinusitis with fungal sinusitis (AFS) was first described by Millar in nasal polyps, inhalant atopy/ IgE mediated 1981 as “allergic aspergillosis”. A subsequent study 3 hypersenstivity, elevated total serum immunoglobulin was done by Robson and colleagues in 1989 and E (IgE), eosinophilia and sinus obstructing they introduced the term "allergic fungal sinusitis". inspissates of a characteristic extramucosal “peanut Allergic fungal sinusitis is associated with nasal 4 butter” or “axle grease” eosinophil rich material called polyps in every case. The overall incidence of allergic mucin4,5, ,Allergic mucin typically cultures allergic fungal sinusitis is estimated at 5% to 10% of positive for fungi but the diagnosis of AFS is made all patients with chronic rhinosinusitis and nasal 4,5,12 1,4,5 6 even if culture is negative . Up to 13% of AFS polyps . The geographic and social factors appear sinus fungal cultures prove to be negative in AFS to have a significant impact on the incidence and confirmed on histopathology9. Allergic mucin is frequency of allergic fungal sinusitis, typically patient responsible for characteristic CT scan finding of is a young adult from warm regions with high 1,4,7 8 central area of hyperattenuation in the sinus cavity humidity and belonging to poor social class . which is one of the diagnostic criteria for AFS2,4. It is a non- invasive disease, representing an allergic Mainstay of treatment of AFS is both medical hypersensitivity response to the presence of extra 9 and surgical debridement of polypi and allergic mucosal fungi within the sinus cavity. Patients often mucin1,7. External radical approaches were used have asthma, allergic rhinitis, eosinophilia, and an previously but now used rarely, these days we use ------------------------------------------------------------------ tissue preserving endoscopic approach.4,5 The use of Deptt. of ENT Nawaz Sharif Social Security Teaching Hospital, postoperative oral corticosteroids1,2,5 and aggressive Multan Road Lahore 13 *Deptt. of ENT FMH College of Medicine and Dentistry Lahore antiallergic therapy is also recommended to Correspondence to Dr. Abdur Rehman, Assistant Professor Email: decrease recurrence after surgery4,7,14. Other [email protected] Cell: 0300-4358054 therapeutic options available include allergen P J M H S Vol. 9, NO. 3, JUL – SEP 2015 875 Evaluation of Allergic Fungal Sinusitis Occurrence in Patients with Nasal Polyps avoidance measures, oral antihistamines, intranasal RESULTS corticosteroids, leukotriene receptor antagonists, and allergen immunotherapy4,11. Role of systemic or local During the study period, we happened to manage antifungal treatment is limited and controvertial4,5. 125 patients with nasal polyps, among them, 85 were The purpose of this study was to find out male and 40 female patients, having mean age of 33 frequency and clinical/demographic characteristics of years (range 09 - 82 years). The patients with allergic allergic fungal sinusitis in patients with nasal polyps fungal sinusitis were 28(22.4%) and remaining 97 treated surgically in this part of the world. were found to have some other cause for the nasal polyps. Among 28 cases of allergic fungal sinusitis MATERIAL AND METHODS cases, proved on final histopathology, mean age was 30 years (range 11-48 years). Male to female ratio This was a prospective, cross-sectional descriptive was 1.4:1(Table 1). study, conducted at Nawaz Sharif Social Security Hospital (NSSSH) Lahore from January 2013 to June Table 1: Gender among patients with nasal polyps: 2015. NSSSH is a tertiary care and teaching hospital Gender AFS* %age Non AFS** %age for University College of Medicine, University of Male 17/28 60.7 68/97 70.1 Lahore. Female 11/28 39.3 29/97 29.9 The study subjects included 125 patients who *allergic fungal sinusitis presented with nasal polyps at NSSSH during the **non-allergic fungal sinusitis period under study. Both male and female patients Table 2: Age and gender distribution of patients with having nasal polyps were included in the study. We allergic fungal sinusitis (n=28). excluded those particular patients from the study who Age (Years) Male Female Total had friable nasal mass (bleed to touch) or did not 10-19 03 02 05 give consent for surgery and histopathlogy. 20-29 05 04 09 These patients were received through casualty, 30-39 06 04 10 Out-patient department (OPD) and as referral from 40-48 03 01 04 other departments. A detailed history was taken; Total 17 11 28 thorough examination of ENT and other systems was carried out by using well illuminated head light and Majority of patients (67.8%) belonged to the group of nasal speculum followed by fibroptic flexible or rigid patients in the age range 20 – 40 years with mean endoscope for detailed inspection. Laboratory age 30.64±S.D 6.03 years (Table 2). investigations included complete blood count, blood urea etc. Besides baseline investigations CT scan Table 3: Social history of the patients (n=28). and MRI of nose and paranasal sinuses were Status n %age performed to know the exact site and extent of Lower Socioeconomic Class* 15 53.5 disease. A well informed consent was taken. All the Middle Socioeconomic Class** 08 28.6 patients underwent nasal polypectomy under general Upper Socioeconomic Class*** 05 17.9 or local anesthesia, mainly by doing endoscopic Rural 20 71.4 sinus surgery and in few cases by external Urban 08 28.6 ethmoidectomy. Note: *Patients having income After surgery collected material which included ≤ Rs: 15,000/ month. mucus together with inflamed tissue and pieces of **Patients having income Rs: 15,000–45,000/ month. polyps was divided into two parts. One part was kept ***Patients having income in sterile tube containing normal saline solution for ≥ Rs: 45,000 / month. direct microscopic examination. The remaining part of surgical specimen was kept in another bottle Majority (53.5%) belonged to low socioeconomic containing formalin and both the specimens were class and from rural (71.4%) area. Unilateral nasal sent to pathology department for histopathological polyps were more frequently seen (64.2%) as and direct microscopic examination. These patients compared to bilateral nasal polyps (35.8%).There were put on topical and oral steroids therapy were 6(21.4%) patients with proptosis, and 3(10.7%) postoperatively and they were followed up for one cases complained of blurred vision whereas 6(21.4%) year. The data was collected using a pre-tested, patients were found to have concomitant asthma structured proforma prepared for the purpose and (Table 4). SPSS version 17 was used for analysis. 876 P J M H S Vol. 9, NO. 3, JUL – SEP 2015 Abdur Rehman, Faisal Rafiq, Athar Adnan Uppal Table 4: Clinical presentation in allergic fungal sinusitis literature reveals that incidence of AFS is higher in Clinical features. n %age warm regions with relatively high humidity2,4,20. Bilateral polyps. 10 35.8 Any gender may be affected; however in this Unilateral polyps. 18 64.2 study males were affected more which is like the Nasal obstruction 28 100 result of Bashir21 who had male: female ratio of 1.4:1 Proptosis 06 21.4 while it is different from Baloch ZA18, where females Blurred Vision 03 10.7 were predominant and Karthikeyan22 who had equal Asthma 06 21.4 sex ratio. AFS may affect any age patient, but in our study most of patients (67.8%) with AFS were in age All patients had surgical treatment. Out of 125, 28 range of 20 – 39 years which is in agreement with (22.4%) patients were reported as non-invasive 23 Shrestha’s study who had 60% patients belonging allergic fungal sinusitis on final histopathology.
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